Preventing Disease in Babies Before Birth Dr. Jodie Benson

www.scientiapublications.com Preventing Disease Fighting Vitamin D in Babies Before Birth Deficiency Before Birth Vitamin D deficiency isn’t just a thing of the past. Dr. Jodie Benson’s research shows that Dr. Jodie Benson a specialist Obstetrician and Gynaecologist at University Hospital Geelong and a senior clinical lecturer at Deakin University identifying and treating vitamin D deficiency in pregnancy can prevent vitamin D deficiency in in Australia. Here Dr. Benson discusses her research into vitamin D deficiency in pregnant women that might adversely affect their babies. the newborn.

Why did you become interested in vitamin D AN OLD DISEASE REARING ITS HEAD AGAIN vitamin D production. Obesity is also a risk deficiency in pregnancy? factor for vitamin D deficiency. The problem is Rickets—fractures and bony deformities compounded in darker pigmented individuals My interest in vitamin D deficiency in pregnancy in infants and young children due to poor and people whose cultural practices include was almost accidental. Not until I spent time calcification of the bones often caused by extensive body covering, both situations with an endocrinology colleague did I become vitamin D deficiency—was probably known decreasing UV absorption by the skin. What aware of the full extent and seriousness of the at least by the first or second century A.D. most concerned Dr. Benson, an obstetrician, problem, especially in newborns. My interest However, rickets was not formally described was the problem of vitamin D deficiency in the was further heightened by the patients who as a specific malady until a treatise in 1645 pregnant women for whom she cared. Since were at risk for this problem. In our clinic these women were often marginalized—not fluent in by Daniel Whistler, an English physician. In foetal vitamin D is acquired transplacentally socioeconomic factors that predispose vitamin D deficiency this should be addressed English and with poor social supports. fact, the term “orthopaedics” was coined by from the mother, low maternal vitamin D pregnant women to have low levels of with vitamin supplementation. the French professor Nicholas Andry –derived levels lead to vitamin D deficiency in the vitamin D in their blood? There was no consensus on how to screen for from Greek words for “correct” or “straight” foetus. Further, breastfeeding does not supply Do you think the public is aware of the or manage the disorder in pregnancy. So in (“orthos”) and “child” (“paidion”)—in his 1741 sufficient vitamin D—especially if the mother Vitamin D deficiency can result from inadequate potential problem low levels of vitamin D this era of evidence based medicine, the idea sun exposure and/or inadequate nutritional pose to the newborn? Should there be more book Orthopaedia: or the Art of Correcting is vitamin D deficient to begin with—so babies of studying vitamin D deficiency in pregnancy intake, as well as from diseases that impair public awareness of the issue? and Preventing Deformities in Children. who have low levels of the vitamin at birth and preventing the birth of vitamin D deficient vitamin D adsorption or conversion into active By 1918, Kurt Huldschinsky, a German cannot catch up with breast milk alone. babies just jumped out at me. metabolites (e.g. liver and renal disease). paediatrician, successfully showed that rickets Typically vitamin D deficiency occurs in I don’t think that the generally public is could be treated by exposure to ultraviolet 25 HYDROXY VITAMIN D LEVELS IN What specific abnormalities in the newborn populations with highly pigmented skin, as well aware of the potential problems that vitamin lamps. This made sense, since vitamin D is PREGNANT WOMEN might someone see if the mother is vitamin D as those with clothing practices resulting in D deficiency poses to adults, children or produced in the skin from the conversion of deficient herself? minimal sun exposure. newborns. There should be more public 7-dehyrdocholesterol by UV radiation. By 1945, To investigate the prevalence of vitamin D awareness in general. Vitamin D deficiency impairs bone rickets had all but been eliminated in developed deficiency in pregnancy and the possibility Increasingly we are seeing maternal vitamin mineralization and leads to bone softening, countries by the enrichment of food, especially of prenatal treatment, Benson and her group D deficiency in a more diverse population. As Given that I’m an obstetrician and but most vitamin D deficient newborns are of milk, with vitamin D via UV irradiation. But designed and carried out a study of pregnant people spend more time indoors for both work gynaecologist. I believe that the pregnant asymptomatic. Softening of the skull bones and domestically, sun exposure is decreased. population should be targeted. Women are rickets, and vitamin D deficiency generally, women attending a routine outpatient may occur, but most alarmingly a neonate This can be compounded by the “sun smart” usually more highly motivated to change any seems to be making a comeback of late. antenatal clinic in a tertiary referral centre in may suffer from hypocalcaemic seizures. message and use of sunscreens. Vitamin behaviours or remedy any ills when they are Melbourne, Australia. Relevant demographic Rickets—bowed long bones—is the typical D deficiency is also increased in the obese pregnant. The family practitioner has the information was obtained from the women, manifestation of long-term vitamin D deficiency population. opportunity to screen and treat the entire family There was no consensus on including socioeconomic status, lifestyle factors but isn’t evident until weight bearing occurs. as well. This is important because studies have such as clothing preference and sun exposure Other associated problems include thinning of how to screen for or manage How do you identify pregnant women shown that if a pregnant woman is deficient, habits. Vitamin D levels were measured by bones—osteomalacia—as well as osteoporosis, the disorder in pregnancy. with low levels of vitamin D and can you her family is also at risk and should be screened. measuring serum levels of 25-hydroxy vitamin increased fracture risk and muscular aches effectively remedy the problem to keep the So in this era of evidence and pains. More recently, vitamin D deficiency D—also known as 25-hydroxycholecalciferol, baby healthy? Do you have plans to extend this study in the based medicine, the idea of has been linked to an increased risk of death a precursor of vitamin D considered the best future or focus elsewhere? studying vitamin D deficiency from cardiovascular disease, as well as indicator of a person’s vitamin D status—and A simple blood test—either prepregnancy in pregnancy and preventing with cognitive impairment in older adults. women with low serum vitamin D levels were or in early pregnancy—can detect vitamin My interest has recently shifted to perinatal loss. Vitamin D deficiency is also associated with the birth of vitamin D deficient D deficiency. Oral supplementation can I sit on the Consultative Council on Obstetric included in the study. Measurements were increased mortality from malignancies—such babies just jumped out at me. commence as soon as the diagnosis is made. and Paediatric Mortality and Morbidity Stillbirth taken both initially and at intervals thereafter, as colon, breast, ovarian, melanoma and Our study showed that if you adequately Subcommittee, convened by the Department including at delivery, as well as from the prostate—as well as an increase in upper and supplement vitamin D deficient women, they of Health. We review all cases of stillbirth in baby after birth. The vitamin D deficient lower respiratory tract infections. Vitamin D and their babies will have normal levels at birth. Victoria. My recent research interest looked Dr. Jodie Benson and her colleagues have women were initially divided into two groups deficiency is also associated with an increase at the feasibility of CT scan versus autopsy in observed that vitamin D deficiency seems to and randomised to receive either vitamin risk of depression and suicide. There is some The option of treating postnatally is also the investigation of stillborn babies. This is a be on the rise in some populations in Australia D supplementation during their pregnancy evidence linking vitamin D to multiple sclerosis, important. Breast milk is not a very good source terribly sad topic and we have to learn more to and elsewhere. They note that lifestyle factors, versus non-treatment. Since there was no type 2 diabetes, inflammation and the risk of of vitamin D—oral supplements must be given. help and counsel families affected by the loss of such as increased time spent indoors and allergies in children and adolescents. standard recommendation for vitamin D Generally, breastfeeding is best for both babies their unborn baby. increasing use of UV-blocking sunscreens, supplementation during pregnancy, the and their mothers, but if the mother is at risk of effectively decrease UV light absorption, hence Are there any specific racial, cultural or withholding of treatment was not ethically

SCIENTIA www.scientiapublications.com Researcher objectionable. However, after delivery any deficiency range, when levels were drawn at women in the non-treatment arm were offered 28 weeks of pregnancy—when other routine Profile treatment with vitamin D for themselves and blood work was drawn—the treatment group their newborns. was now up to an average of 65 nmol/l, while the untreated women had average levels of FACTORS ASSOCIATED WITH VITAMIN D 41 nmol/l. The untreated women were still DEFICIENCY deficient, below 50 nmol/l, while the treated women were now in a borderline zone between Benson’s study initially enrolled and 50-75 nmol/l. And at that point, the dosing of randomised 78 pregnant women, although vitamin D supplementation in the treatment at the end of the study 45 women were group could be doubled—from 2000 IU of available for data analysis, 22 in treated and ergocalciferol (vitamin D3) to 4000 IU—to see if Dr. Jodie Benson 23 not treated, some women being lost due to more was better, and also to see if a higher dose Obstetrician and Gynaecologist Specialist and compliance and other issues. The women in was tolerated in pregnancy. Clinical Lecturer both groups were similar in age, 28-29 years, University Hospital Geelong and Deakin University and had only been in Australia for 6-8 years. At delivery, the level in the treatment group had Thus, younger immigrants represented a goodly risen to 71 nmol/l, now in the recommended Dr. Jodie Benson received her Bachelor of portion of the study population. Perhaps as normal range, while the level in the untreated Medicine & Surgery from the University of expected, approximately 75% of these vitamin D group was still in the deficiency range, at 36 Melbourne. She completed formal specialist deficient women were dark skinned and about nmol/l. Beyond that and most importantly, training in Obstetrics & Gynaecology at Monash 15% wore veils and extensive body coverings. the vitamin D levels in the newborn babies Medical Centre, being elevated to Fellow in 2011. Both of these situations are associated with low correlated with the maternal vitamin D levels. In Her early career featured international experience levels of vitamin D. Also, dairy intake—including the treatment group, the 25-OH vitamin D levels including a Fellowship in Robotic Gynaecological & Endoscopic Surgery. This time abroad also vitamin D fortified milk—was similar, at about averaged 81 nmol/l, compared to 42 nmol/l in ignited a passion for intrapartum care and labour 8-9 servings per week. Importantly, about a the untreated group, a significant difference. ward teaching, having worked in a busy obstetrics fourth of the women had a previous history of The treated babies had normal vitamin D unit in Ireland delivering close to 10,000 babies vitamin D deficiency. levels—presumably keeping them safe from a year. She returned to Australia in 2010 and rickets and other manifestations of vitamin D worked at South West Health care and Deakin At the first visit—between 12-16 weeks of deficiency—while the levels in the untreated Warrnambool, where she was the Women’s gestation—the 25-OH vitamin D levels in these group were in the deficient range. Benson’s Health rotation coordinator, before moving to two groups of women was approximately the hypothesis was confirmed—treating the mother Geelong. Dr. Benson combines her clinical role at same and low. In the treatment group, the with vitamin D before pregnancy significantly GUH, with RANZCOG training supervision, Deakin serum level averaged 32 nmol/l, while in the improves the mother’s vitamin D levels, but it medical student teaching as well as sitting on the placebo group it was 33 nmol/l. Although no also raises her baby’s levels so it can be born Consultative Council on Obstetric and Paediatric official recommendations existed at the time for with normal levels of vitamin D. Screening and Morbidity and Mortality (DHS). vitamin D levels in pregnancy, Benson and her treatment appears to be a reasonable strategy CONTACT colleagues used clinical guidelines published to combat maternal and foetal vitamin D T: +61 3 421 50000 in 2011 by American endocrinologist Michael deficiency. E: [email protected] Holick and his colleagues that considered the normal level of 25-OH vitamin D to be Benson admits that this is a small study and KEY COLLABORATORS >75 nmol/l, while deficiency was defined as technically not extremely rigorous. However, Christina P. Rodda, University of Melbourne a level <50 nmol/l. Clearly, both of Benson’s the results speak for themselves and, combined Amanda J. Vincent, Monash University patient groups were significantly deficient in with research by other groups, the study gives Clare L. Whitehead, University of Melbourne vitamin D, putting themselves and their babies clear evidence that supplementing vitamin D Alex Polykov, Royal Women’s Hospital, Parkville, at risk for the adverse effects of vitamin D in pregnancy remedies vitamin D deficiency Victoria deficiency. Benson and her co-workers found in pregnant women themselves and prevents Beverley Vollenhoven, Monash University what they had expected—pregnant women neonatal vitamin D deficiency. The results of with recognized risk factors having significantly Benson’s study indicate that larger studies FUNDING Australian and New Zealand College of Obstetrics low levels of vitamin D. So did the vitamin D are needed to verify the results, determine and Gynaecology Research Foundation supplementation work? the optimum levels of vitamin D in pregnancy Luke Proposch Perinatal Research Scholarship and how much supplementation should be SIGNIFICANT RISE IN VITAMIN D LEVELS given, and generate guidelines that can then be applied to all prenatal patients. But the die When Benson analysed the 25-OH vitamin D is cast in this battle against the resurgence of levels over the course of the pregnancies in neonatal vitamin D deficiency. both groups, she found the very answer she was looking for. While both groups had levels of 32-33 nmol/l at the beginning, both in the

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